Academic Consultation Form - Epidermal Cell Therapy

Name

First Last

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Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

Home Phone

Cell Phone

Work Phone

Age

Marital Status

If married, is your spouse active duty military?

Yes
No

Do you have children?

Yes
No

How many children?

What is the age range from youngest to oldest?

e.g. 2 yrs – 12 yrs.

How long have you been a Virginia resident?

If not from Virginia, what state do you originate from?

Are you a high school graduate?

Yes
No

What year did you graduate?

Have you continued your education beyond the high school level?

Yes
No

Additional Education

(Please check all that apply)

Select All
Trade School
Vocational Center
College (Community or University)
Other

Are you currently employed?

Yes
No

How long have you been employed with your current place of employment?

Give a brief description of job title/responsibilities for your current position:

Do you have other employment history previous to your current employment?

Yes
No

Give a brief description of previous employment history:

Are you currently working in a salon/spa?

Yes
No

Which establishment do you work at?

How long have you been employed there?

Which categories are you currently licensed in?

(Select all that apply)

Esthetics
Hair Removal
Nails
Cosmetology
Massage Therapy

Are you an esthetics, cosmetology, medical, spa, nail, school owner, manager, or other type employee?

Yes
No

If yes, please list business name:

What do you know about the esthetics industry?

What type of esthetic services have you had performed on you as a client:

(Select all that apply)

Basic Facial
Body Treatment
Microdermabrasion
Waxing
Chemical Peel
Makeup Application

How strong is your interest in becoming an esthetician?

Undecided
Interested
Extremely Interested

How did you hear about our institute?

How strong is your interest/commitment to becoming a student again?

Undecided
Interested
Extremely Interested

Have you researched/visited other schools in the area that offer an Esthetics programs?

Yes
No

In researching other educational options, what did you find about the other schools that you most LIKED?

In researching other educational options, what did you find about the other schools that you disliked or LEAST liked?

After hearing the overiew of each of course, which program/programs offered by The Institute of Epidermal Cell Therapy would you have an interest in?

(Please check all that apply)

Basic Esthetics
Master Esthetics
CEU (Continuing Education Courses)

Which session best suits your schedule and scholastic needs?

Full Time
Part Time
Online

How would you rate your interest level in regards to enrolling in The Institute of Epidermal Cell Therapy?

Undecided
Interested
Extremely Interested

Which enrollment opportunity do you feel would be of interest to you?

Basic Esthetics State Board Focus only
Basic & Master Esthetics Focus only

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